Healthcare Provider Details

I. General information

NPI: 1124066956
Provider Name (Legal Business Name): GWENDOLYN JANE SIMONS PT,JD,OCS,FAAOMPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 MAIN ST SUITE A
SANFORD ME
04073-3606
US

IV. Provider business mailing address

1068 MAIN ST SUITE A
SANFORD ME
04073-3606
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-6789
  • Fax: 207-324-9394
Mailing address:
  • Phone: 207-324-6789
  • Fax: 207-324-9394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT2727
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: